Category Archives: medical education

Primary care’s bad rap

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Primary care’s often-negative reputation as stressful and unrewarding apparently starts early in the medical education process – possibly before students even enter medical school, a recent study has found.

The study appeared earlier this year in the Family Medicine journal. More recently, the findings and their implications for family practice medicine were explored in an interview by the American Academy of Family Practice with one of the study’s authors, Dr. Julie Phillips. an assistant professor of family medicine at Michigan State University College of Human Medicine.

Primary care has struggled for several years with perceptions that it’s boring, stressful, demanding, low-paying and hemmed in with constraints on everything from insurer requirements to time pressures in the exam room. Whether this is perception or reality, it has had an impact: Fewer students who enter medical school are choosing a career in primary care.

The authors of the study wanted to learn more about how primary care is perceived by medical students and whether their perceptions are changed by what they experience during their training.

Surveys were conducted among 983 medical students at three medical schools between 2006 and 2008. The students were asked to rate statements such as “primary care physicians have too much administrative work to do” and “time pressures keep primary care physicians from developing good patient relationships.” Similar questions were posed about the students’ perception of specialty physicians.

Perhaps the most eye-opening conclusion of the study is this: Negative views of the daily routine of primary care were already present in many of the students at the beginning of their training. What’s more, these views didn’t really change as students progressed through medical school, even after they had a chance to directly observe and participate in patient care.

What to make of these findings? It’s clear that “contemporary physicians struggle to meet the high expectations set by patients and their profession with limited time and resources,” the authors wrote. “Our date demonstrate that students are paying attention to the struggle.”

The results were “kind of discouraging,” Phillips told AAFP News Now. She said she also was surprised that the students’ perceptions were formed so early. “That makes me think that some of their views of what it’s like to be a doctor actually don’t come from medical school but from the larger cultural perception of what physician work is like – and especially what primary care is like.”

There were some glimmers of hope. Students who completed a primary care clerkship (typically during the third year of medical school) and had seen real-life primary care in action were more positive about the ability of primary care doctors to develop good relationships with their patients, in spite of the time constraints in the exam room. “It may be that actually spending time observing physicians helps to break some negative stereotypes,” the study’s authors noted.

The researchers also learned that some students will choose primary care regardless of their perceptions about the daily grind. This suggests that individual values and goals play an important role in the career choices of medical students, the authors wrote. “The study reinforces the importance of admitting students with primary care-oriented values and primary care interest and reinforcing those values over the course of medical school, if we are to produce greater numbers of primary care physicians.”

We’ve come a long way from the romanticized ideal of the family doctor that prevailed a generation or two ago. But did the ideal ever really match the reality? If you talk to physicians privately, some of them will admit there’s a great deal of grumbling about the profession and not enough focus on what makes it rewarding. To be sure, there are all too many reasons for doctors to be frustrated and exhausted and discouraged, but at what point do the negatives start to drown out everything else?

Phillips challenged the medical profession to become more involved in supporting new models of care, such as the patient-centered medical home, that can breathe new life into primary care and make it a better career choice. Family doctors also should try to share what’s good about their specialty, she said. “Students listen to what we say. We should try to be positive about the great things in our everyday work, because there are many wonderful things about being a family physician.”

The decline of empathy

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It’s probably safe to say that most medical students start their training with a high desire to be empathetic toward their patients.

But these ideals often don’t survive the grueling process of becoming a doctor, a recent study published in the American Journal of Pharmaceutical Education has found.

Researchers at Midwestern University in Chicago and Thomas Jefferson University in Philadelphia wanted to know whether exposing first-year medical and pharmacy students to a theatrical exercise depicting the challenges of aging would improve their ability to empathize.

It did. The study involved 370 students at the Chicago College of Pharmacy and the Chicago College of Osteopathic Medicine at Midwestern University. They were asked to complete a test measuring their empathy levels before and immediately after the skit, and they scored significantly better afterwards. Unfortunately, though, the effects weren’t long-lasting. When the empathy test was administered again (one week later for the pharmacy students, 26 days later for the medical students), most of the scores had returned to their original baseline.

This doesn’t necessarily mean these students were completely lacking in empathy. But it points to the difficulty of instilling and maintaining this quality in the future health care workforce as they progress through their training.

Previous studies have reinforced this. The one that’s probably cited the most often appeared in 2008 in the Academic Medicine journal and examines what the authors describe as “hardening of the heart” during medical training. It tracked four classes of students at the University of Arkansas for Medical Sciences and documented notable declines in empathy scores, especially after the first and third years of medical school.

Similar findings have been reported among students in dental school and in postgraduate medical education.

Given the intensity of medical training, it seems inevitable that students would undergo some hardening of the heart, if for no other reason than to cope with the sheer burden. The academic demands are rigorous. The reality of providing care for actual patients, which starts in their third year, can be overwhelming and disillusioning for many students, especially when patients die or don’t fare well. Training environments that place medical students at rock-bottom in the pecking order are exhausting at best and abusive at worst. Add in the ever-present anxiety about grades and educational loans, and it’s no wonder that empathy begins to take a back seat.

Here’s a peek at the emotional state of a second-year medical student at Johns Hopkins who is about to transition into hospital training:

Suddenly the theoretical becomes practical, the “nice-to-knows” become “must-knows,” and simple clinical scenarios become ethical dilemmas. The vicissitudes become quite intense: one moment you feel ready to save a life as you stand triumphant over a mannequin, then suddenly you’re hovering in the pediatrics emergency department hearing the gurgle of a seizing child and feel completely helpless to handle such situations.

But it all begs the question: Is empathy something you can teach to medical students, or is it innate? If it’s teachable, can the curriculum be strengthened to foster and develop empathy? If it’s innate, should the admission process put more emphasis on selecting students who have this quality?

The 2008 study in Academic Medicine uncovered some interesting nuances. Overall, students who chose specialties in fields with a high amount of patient contact and continuity of care – family medicine, internal medicine, pediatrics, obstetrics-gynecology, psychiatry – had higher scores on the empathy scale than those in other specialties such as surgery or radiology. Male students in the core specialties actually scored higher than the population norm at the beginning of their training. On the other hand, the largest decline in empathy scores took place among male students in non-core specialties. Meanwhile, female medical students started at the norm and scores then declined for females choosing non-core specialties.

Of note, few if any of these students entered medical school with a deficiency in their empathetic abilities. But something about the training process may have diminished their capacity to feel empathy for others. To date there haven’t been many studies to determine whether this is temporary or whether it persists throughout their career. The study in the pharmacy education journal suggests that even when students are exposed to academic exercises specifically designed to increase their empathy, the effects may be short-lived.

Despite a lot of study, especially in the past decade or so, there remain many questions about how best to foster empathy in students who will be spending the rest of their working years in patient care. It matters because patients are more likely to comply, more likely to receive an accurate diagnosis and more likely to be satisfied with the clinician-patient relationship when empathy is present, the pharmacy journal authors wrote. “Empathy is an important component of the healthcare provider-patient relationship that has been linked to optimal patient outcomes.”

A new breed of doctor

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Most people probably skipped right over the announcement late last week, but for anyone thinking about going to medical school, it was pretty big news. For the first time in 20 years, the Medical College Admission Test, or MCAT, has been revised.

Starting in 2015, students who aspire to become doctors will be tested on more than just their knowledge of the sciences. They’ll also need to have a good understanding of psychology, sociology and biology and how these forces help shape individual health and behavior.

How best to educate future doctors has long been a subject for debate. Should students be accepted into medical school on the basis of their grades and test scores alone, or should other factors be considered as well? How important is it for pre-med students to have a grounding in non-science disciplines such as psychology or the humanities? Who’s likely to make a better doctor – someone who’s outstanding in science but mediocre in people skills, or someone who’s merely good in science but excellent in people skills?

The MCAT matters because it’s one of the major determinants for who gets into medical school and who doesn’t – and, ultimately, what the future physician workforce will look like.

The revisions to the exam have been brewing for many months and reflect an ever-broadening definition of what it takes to be a good doctor. It’s no longer enough to be a science nerd with a solid background in organic chemistry. As Dr. Darrell D. Kirch, president and CEO of the Association of American Medical Colleges put it, “it also requires an understanding of people.”

The new version of the MCAT adds two sections: one on the psychological, social and biological foundations of behavior, and one on critical analysis and reasoning skills. A writing section has been dropped but the rigor of the science sections remains unchanged, and the test will still be a marathon. It’ll take students about six and a half hours to complete the whole thing, versus the four and a half hours it takes now.

I checked out an online preview guide for the test. Make no mistake, it’s very difficult. Here’s a sample question from the new section on the psychological, social and biological foundations of health: “How does cognitive dissonance explain the occurrence of persistent conformity? Memories change to reduce discomfort resulting from providing answers that differ from: A. answers identified as correct. B. memories of others. C. previously provided answers. D. original memories.” (The answer is D.)

Curious to know what pre-medical students think of these changes in the MCAT, I visited an online student doctors forum, where most of the reaction can be summed up in one word: “Brutal.”

“I think we lucked out not having to take this,” one pre-med student commented.

MedPage Today interviewed an aspiring doctor who had a different perspective. Adam Gardner, 29, earned a master’s degree in international affairs, then decided he wanted to become a doctor. He’s currently loading up on science prerequisites in preparation for taking the MCAT in June.

He said that while he appreciates the idea behind trying to create a more well-rounded doctor who can interact on a deeper level with patients, he worries that the additional test sections may require students like him who decide later in life to go to medical school, to take a greater number of classes in order to prepare for the test.

“Adding these new things to the test could drag this out even longer for people who want to get it done,” he said.

But then again, Gardner said having a knowledge of social sciences would lead to a better doctor-patient relationship.

“I’ve met a lot of doctors … and some of them are pretty cool people,” he said. “But a lot of them are not terribly social and easy to get along with, and I think having a more rounded background will create doctors who can deal with patients better.”

Critics didn’t waste any time weighing in with their reaction to the newly revised MCAT. One of the objections being voiced most frequently is that the heightened emphasis on psychology, sociology and critical thinking skills is too “touchy-feely” and will have the effect of dumbing down the test, thereby lowering the bar for who gets admitted to medical school.

It’s a valid concern. You could just as easily argue, however, that a medical school admissions process that’s structured in favor of the sciences can end up unfairly excluding students who are well-rounded, hard-working, took all the right pre-med college courses, earned good grades, have all the makings of becoming a good doctor but simply didn’t do as well on a science-oriented test.

It comes back to the original question: What are the most important qualities for doctors to have? Knowledge of the sciences will always be critical, but is there room for training programs to also emphasize analytical thought, the social sciences and the underpinnings of human behavior? The new version of the MCAT suggests that indeed there is. In 20 years or so, we’ll find out whether it’s made a difference.

‘This is where I belong’

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Nine months of hands-on clinical training, seeing patients and working with physician mentors at Affiliated Community Medical Centers reinforced the desire of Sarah Eisenschenk, now a fourth-year medical student at the University of Minnesota, to become a rural primary care doctor.

“I guess I found out that this is where I belong!” she concludes in an essay posted this past summer on the Discover ACMC blog.

When you get right down to it, all health care ultimately is local – and you can’t have a good local health system when the right people aren’t in place.

Much has been written about the supply of physicians in the U.S.: how there aren’t enough of them, how specialties such as primary care and geriatrics are in short supply, and the geographic imbalances that leave some urban areas with a surfeit of physicians while rural and/or remote communities go begging.

As someone who lives in rural Minnesota, I’m keenly aware of how much it takes for local providers to attract and retain qualified doctors. They’ve notched up several successes in the past couple of years, but they can’t ever really stop recruiting because they know that a departure or a retirement, or a decision to expand a service – cardiology, for instance – could change the whole situation.

We don’t seem to be alone. The Association of American Medical Colleges projected last year that the national shortage of physicians could reach 62,900 doctors by 2015 (that’s just three years away) and 91,500 by 2020.

I was therefore taken aback when I recently came across some reports suggesting the doctor shortage isn’t as bad as it’s made out to be. According to data released by the Association of American Medical Colleges, there were 258.7 active physicians for every 100,000 Americans last year. More than six in 10 physicians settle in the state where they received their medical education, the report found.

This month the Colorado Health Institute issued a report on the state’s health care workforce and the impact of adding the uninsured to the health insurance rolls when this provision of the Affordable Care Act takes effect in 2014. The report’s conclusion: There’ll be a need for more health care providers but it won’t be as dramatic as many anticipated.

Here’s a final piece of data: First-time applications to medical school reached an all-time high this year, according to the Association of American Medical Colleges. Medical students are increasingly diverse, and the majority start their training with some previous exposure to clinical experiences.

While all of this sounds positive, the picture becomes more complex when you start studying the details.

The Colorado Health Institute report, for instance, is careful to point out that rural areas are, and will continue to be, short of doctors. Nor did the report take into account the impact of an aging population or the increasing trend among physicians to specialize rather than go into primary care.

The situation also varies considerably from state to state (click here to see an interactive map put together by American Medical News). Some states do very well at retaining physicians after they complete their training at one of the state’s medical schools. Alaska, California and Montana manage to keep 60 percent or more of their medical school graduates in the state. New Hampshire is the worst, exporting all but 28.3 percent of its graduates. The Upper Midwest is somewhere in the middle; of the 17,516 medical graduates whose training was in Minnesota, 7,735 – or 44.2 percent – remained in Minnesota to practice medicine.

Dig deeper and you’ll find that although Minnesota has 269.6 active physicians for every 100,000 residents, a figure that puts it among the best 15 states in the U.S., the number of active primary care physicians is 103.8 per 100,000. Moreover, 22 percent of all physicians in Minnesota are over the age of 60 and presumably beginning to think about retiring.

It’s not a time to get complacent, which is why I’ve found it encouraging to read the many physician stories posted at the ACMC blog. One of the most recent comes from Dr. Michelle Cilek of ACMC-Redwood Falls, who describes the rewards of being a family doctor in a smaller town where she can practice quality medicine yet still have time to garden, sew and attend her children’s soccer games. “Redwood Falls is a great community; my practice is busy and I am able to get to know my patients on a more personal level because I see them at church, my children’s activities and more,” she writes.

Dr. Merlin Nelson, a neurologist, likes the challenge of the variety of patients he sees. Being a five-minute drive away from the clinic or hospital when he’s on call is a pretty good deal too. ACMC physicians in Granite Falls, Litchfield, Marshall and Willmar share their stories here, here, here and here.

To the average patient, what matters most is having a doctor quickly available when the need arises. Issues of supply and demand, of geographic distribution, specialty distribution, availability of training slots and even the increasing burden of medical training costs can seem rather remote and academic. But making all the pieces come together is much harder than it looks, and it’s all the more rewarding to see when this happens in your own backyard.

Illustration: “Doctor and doll,” Norman Rockwell, 1929

Nurturing rural health

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What does the University of Minnesota Medical School have in common with rural health care?

Readers of the Star Tribune of Minneapolis may have noticed a front-page story this past weekend about a financial crunch afflicting the U of M Medical School. Although the situation is improving, there’s been severe belt-tightening, and the medical school could get hit again with cutbacks in state funding.

What really caught my attention, though, was three paragraphs near the end of the news story:

Dean Aaron Friedman said the Med School could probably withstand a 5 or 6 percent cut in state funding without losing programs. But if Senate discussions of an 18 or 19 percent cut materialize, the school will have to drop operations that aren’t essential for accreditation, he said. He would aim first at nonessential programs that help deliver health care and physicians to outstate Minnesota.

“We’d have to reduce those services in the next fiscal year,” Friedman said.

Another potential hit could come from a state-funded program that pays hospitals, clinics and other health care providers to train medical students. A potential trickledown effect would be a shrinking of Med School enrollment for lack of training positions.

There are few details at this point for what might happen, but I think it’s safe to say that if some of these cutbacks come to pass, rural Minnesota will feel the effects.

Although there are many strategies for building up the rural health care workforce, providing training opportunities in rural settings is an essential one. Research has consistently shown that when students in the health professions have the opportunity to do a clinical rotation during their training, they’re more likely to consider rural practice as a career choice.

Here’s one successful example: the U of M Medical School’s Rural Physician Associate Program, an elective program that allows third-year medical students to spend nine months living and working in rural communities.

From 1971 through 2008, there have been 953 students who have participated in the program. More than three-fourths chose specialties in family medicine, internal medicine or pediatrics. The majority also stayed in Minnesota when they finished their training. Overall, more than half opted for rural practice.

It takes money and resources, of course, to offer programs like this. The rural clinics and hospitals who agree to be training sites do so because they believe in the value: What they do today can help create health care professionals for tomorrow. At some point, however, it can become unsustainable for them if they don’t receive at least a small amount of funding to offset the cost.

If you combine this with less educational outreach for rural health and a reduction in medical school admissions, some form of blowback is probably inevitable.

It’s obviously too soon to know how the U of M Medical School’s situation will play out in the months ahead. Considerable discussion and funding decisions still need to happen, and nothing is a done deal at this point. But if some of these training initiatives are indeed cut back, especially in rural health, it’s bound to hurt. The effects might not be felt right away, but they would eventually become apparent as doctors begin to retire and can’t be replaced.

Issues at the U of M Medical School and the state Capitol might seem abstract and far away. In reality, this is one issue that hits pretty close to home.

Photo: Wikimedia Commons

The evidence on empathy

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Empathizing with patients often can help make them feel better, at least emotionally. But can it also result in measurably better outcomes in their health?

A new study from the Academic Medicine journal has put another brick in the wall of evidence shoring up the value of empathy. The research involved 891 patients with diabetes and 29 family physicians who were treating them. The doctors were asked to complete an assessment evaluating where they were on an empathy scale: high, moderate or low. Then they were compared against patient outcomes.

As you might have guessed, patients whose doctors had a high empathy score were significantly more likely to have better control of their diabetes than patients whose doctors were low in the empathy department.

Why, then, is it often so hard to convince physicians that being nice to their patients is more than just touchy-feely psychobabble? wonders Stephen Wilkins, a former health care executive and consumer behavior researcher who blogs about doctor-patient communication at Mind the Gap. He writes:

The problem with empathy research is that no one, including doctors, seems to be paying attention as attested to the fact that nothing has changed. Research documenting the therapeutic value of empathy goes back at least 20 years. Despite the evidence, it seems that physicians are no more empathetic today than when people first started researching empathy.

I’m not sure I would agree that nothing has changed. Health care organizations are paying attention to customer service and patient satisfaction in ways we didn’t see 10 or 15 years ago. Although there are still more than a few health care professionals who haven’t gotten the message, or who think empathy doesn’t matter that much, the majority seem to at least be making an effort.

The bigger question, it seems, is how to successfully instill empathy in the first place, and how to maintain it amid the increasing pressures of the health care work environment.

Is empathy something that can be taught to medical students? To some extent, the answer is yes. Communication skills are part of the curriculum at virtually every medical school in the U.S. Part of the process of becoming a doctor, after all, is learning how to effectively interact with the human beings who are your patients.

What’s disturbing is some of the evidence suggesting that medical students often begin to lose their empathy by the third year of their training. A study that appeared in September 2009 in Academic Medicine created quite a stir when it was published. The authors tracked matched cohorts of more than 400 students through medical school, from their first day to the end of their final academic year, and found a significant decline in empathy scores after the third year. The decline was greater for males than for females, and also was greater for students in technology-oriented specialties.

Not coincidentally, the third year of medical school is when students really begin to dive into hands-on patient care and start experiencing the reality of practicing medicine. This, along with the demands of the training process, may be what erodes empathy, the study’s authors wrote. Their findings are echoed in a number of previous studies examining everything from sleep deprivation among medical students to abusive training environments.

This issue doesn’t seem to be confined to the United States. A recent Twitter conversation in the U.K. raised similar points. Among some of the observations: Even with an emphasis on the importance of empathy and good communication, medical students often don’t put these skills into practice. For many students, distancing themselves from patients can in fact become a necessary coping mechanism. “If you felt every bad outcome you wouldn’t survive your MS3 year in [the] US,” a student tweeted. Someone else observed, “Committed people keep empathy, but some do lose it.”

Empathy can be even more challenging once students graduate from medical school and enter the real world of day-to-day medical practice with all its paperwork and the twin pressures of time and productivity.

So what’s the real issue here? Is it that doctors remain unconvinced that empathy makes any difference in their patients’ health? Or does it lie in the difficulty of sustaining an empathetic state of mind day in and day out in the demanding environment of patient care – and if so, how can this be changed?

Image: “Consolation,” Odette Sculpture Park, Windsor, Ontario; courtesy of Wikimedia Commons

Primary care’s image problem

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From the doctor’s point of view, is primary care rewarding or is it just plain boring?

Medical student Suchita Shah spent five weeks awhile back doing a clinical rotation at a primary care and general internal medicine clinic.

She blogged about the experience a few months ago. Then her blog entry was picked up at Kevin, MD, one of the leading voices in the medblogging world, which is where I discovered it. It seems to sum up many of the issues ailing primary care these days: namely, that many (maybe even most) medical students no longer seem to find it worth their while.

Shah writes:

It was awesome because I was the “doctor.” I essentially had full responsibility for each patient. From calling him in from the waiting room to deciding what medications he needed and at what dose, and everything in between, he was my responsibility. After I saw the patient, I’d present the case to my attending for a few minutes, we’d discuss and he’d teach for a minute and modify my plan a little if necessary, then the real doctor would go in and say hello and sign the orders I had suggested. I was my patient’s health care provider – a phenomenal feeling and an awesome transition in that I now think of myself as a capable clinician-in-training.

But that’s why I found primary care to be boring. I could do it. As a 3rd-year medical student. The cases I saw were by and large obesity, hypertension, diabetes and hyperlipidemia. A little tweaking of drug doses here and there, lots of education about lifestyle changes, plenty of questioning to assess for target organ damage, referrals for specialist followups… and far too much of “staying the course.”

Medical students and doctors like to be challenged and this wasn’t challenging, she writes. “And if this is what most of family medicine/primary care is like… I don’t want to do it for the rest of my life.”

Houston, I think we have an image problem.

To be sure, there’s a lot that’s frustrating these days for primary care physicians. There’s the paperwork, the crummy reimbursement, the pressure to churn patients through the exam room. But are these reasons to disdain the entire field of family medicine or general internal medicine?

The responses to Shah’s guest blog were interesting. “ALL of medicine is boring. And/or frustrating, time-consuming, aggravating or headache-inducing. Welcome to the real world,” one physician wrote.

From another doctor:

really? as a med student, u really feel like u have mastered primary care medicine? as a professor of medicine, i have a reference point, and i can assure u that u have not.

If you spend much time reading blogs and online discussions among medical students, however, the attitude that primary care is unexciting is far from unusual. And it’s not clear how much of this is based on reality and how much is perception.

It’s true that primary care doesn’t pay as well as most of the specialties. For medical students lumbered with enormous educational loans, career decisions often come down to the financial realities. It doesn’t seem to be only about the money, though; there also seems to be a perception that primary care itself isn’t interesting enough or worthwhile enough to be the focus of one’s career.

An article published a couple of years ago by the Association of American Medical Colleges reflects on why this is so. The devaluing of primary care isn’t new, and it often starts in medical school with a so-called hidden curriculum that devotes fewer resources to learning primary care, fewer good opportunities for students to experience primary care firsthand, and often even subtle discouragement or disdain by medical school faculty, the article explains.

But the article also hits on another factor: the high expectations of many medical students for a career that’s both intellectually and financially rewarding. These students, after all, are quite elite – very bright, very hard-working, competitive and achievement-oriented, with high aspirations for their future – and this sometimes leads to feelings of entitlement. When this is the mindset, primary care often simply can’t compete, especially if students perceive (mistakenly) that it’s easy enough for any rookie to do.

Primary care obviously isn’t suited for everyone. In the final analysis, students need to choose a specialty that’s a good fit for them, and the American health care system needs a good supply of specialists as well as primary care doctors.

But it would be too bad if students wrote off primary care on the basis of a limited experience that may not have been representative.

It looks as if Shah may have completely missed what makes primary care interesting and challenging, a physician commenter wrote: “Every patient encounter is an opportunity to discover something and someone new. I chose primary care partly because I didn’t want every patient of the day to be a life and death situation. I am happy to be brilliant once or twice a day and very much enjoy discovering what makes each of my patients tick, what they love and hate and why they make the health choices they do. I love to hear about their jobs and hobbies and families, their grief and their joy. I can always find a way to plant a small seed of better health in each of their lives. I love my job!”

Update: Results from Match Day on Mar. 17 show an uptick in the number of medical students obtaining residencies in primary care. The National Resident Matching Program reports that the number of U.S. medical school seniors matched to a residency in family medicine rose by 11 percent this year. There was an 8 percent increase in the number of matches to internal medicine and a 3 percent increase in pediatric matches.

The numbers are a little bit misleading because the overall number of residency training slots in primary care has been increased. Family medicine programs, for instance, are offering 100 more positions this year. The number of Match Day applicants for all specialties also is up overall.

According to this year’s Match Day statistics, dermatology, orthopedic surgery, otolaryngology, plastic surgery, radiation oncology, thoracic surgery and vascular surgery remain the most competitive specialties for applicants.

Match Day helps determine where fourth-year medical students will spend the next three to five years completing their residency training. It’s usually predictive of the student’s ultimate choice of specialty.

Photo: Wikimedia Commons

When the clinician is a student

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Having a thyroid ultrasound a few years ago was no big deal, but I was a teensy bit taken aback to learn the exam would be done by a radiologic technology student.

Only for a few seconds, though. The tech was careful and professional. And if I hadn’t been told he was a student, I don’t think I would have known the difference.

Sooner or later, students in the health care professions are forced to get out of the classroom and start developing their skills on real-life patients. It’s a necessary part of the learning process. But how do patients feel about it? More to the point, how should they feel about it?

There’s been a hot online debate this past week at Kevin, MD, on the topic. It started as a discussion about whether medical students should remain exempt from liability if they harm a patient, and swiftly evolved into a bigger conversation about what patients owe medical students and vice versa.

Should patients be expected to allow medical students to practice on them for the greater good of society? No way, according to one of the commenters:

One of my family members had a poor outcome as a result of a student’s ineptitude and the physician’s inadequate supervision. No lawsuit, but we learned a lesson: from now on, students can practice on the family members of physicians, not on members of my family.

Wait a minute, protested several physicians and medical students. Isn’t it important to give students a chance to learn? “Patients DO benefit from having students involved in their care because today’s students are tomorrow’s doctors,” one person wrote.

There’s a shortage of studies that examine patient preferences on this issue. Most, however, suggest the majority of patients don’t mind – and often even welcome – being cared for by students. A study among obstetric patients found that women who consented to having a student involved in their care were usually motivated by a desire to contribute to the student’s education. When women refused, the reason cited most often was privacy concerns.

A similar survey of 575 family medicine patients found that 90 percent were willing to be seen by a student. Most of them also perceived it was beneficial to their care.

There are ethical boundaries here, of course. If one of the clinicians is a student, patients should be told. Patients have the right to refuse to be a teaching tool for students and not be penalized for it. Nor does being admitted to a teaching hospital automatically mean the patient has consented to having students involved in his or her care. (One study done in the U.K. among elderly patients found that many didn’t understand what a medical student was, even after being interviewed and examined by a student.)

So why would you want a medical student to care for you? Dr. Vineet Arora, an associate program director for the internal medicine residency and assistant dean of scholarship and discovery at the Pritzker School of Medicine for the University of Chicago, answers the question:

Someone will check in on you frequently and have time to listen to your questions. – Because medical students often don’t have the caseload of the resident or attending, the student is able to pay more attention to you throughout the day. A third year student may be following only one or two patients at a given time. While it is true that maybe they don’t know all the answers to your questions, they can relay this to your team and often serve an invaluable role.

They may make you feel better. - Students are often less burned out and more connected to their patients since they are learning from each of their interactions. I’ve had students who really connect to patients through a variety of ways to help them heal, including reading to them or bringing them their favorite magazines or books so they don’t get bored.

Student doctors also can help with crucial things such as obtaining a complete history and physical and tracking down old medical records, Dr. Arora wrote. In some cases, they’ve even helped make an unusual diagnosis, she said.

The radiologic technology student who did my ultrasound has been a full-fledged tech for a few years now. In fact, when I saw him he was near the end of his training. Most likely he has done many ultrasound exams since then, contributing in some way to the care of hundreds of patients. It’s rather cool – dare I say rewarding? – to have had the opportunity to be part of it.

What do readers think? Would you welcome having a student involved in your clinical care? Why or why not?

Photo: Neil Patrick Harris in “Doogie Howser, MD,” ABC Television

The price of educating health professionals

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At one time you could find dozens of small programs for training nurses, laboratory technologists, radiologic technologists and other health care professionals. But one by one, they began to disappear.

One of the last of these programs in the region, the School of Radiologic Technology at Rice Memorial Hospital here in Willmar, became the most recent casualty this week, when the hospital announced the program will be discontinued after the final class graduates in 2012. The reason: The hospital simply couldn’t afford the cost anymore of supporting the two-year training program.

Increasingly, the education and training of future health care professionals is becoming an expensive proposition. Part of this is due to the growing volume of skills, competencies and knowledge that would-be professionals are required to master, whether they plan to become a dental hygienist, nurse, physician assistant or doctor. They’re simply expected to learn more, period, and it takes resources to adequately prepare them for a professional career.

The other, and singular, piece of the equation, however, is the cost of clinical training. Health care professionals cannot acquire all their skills in the classroom. At some point they must gain real-life experience with real patients. The only way to become a good surgeon, after all, is to do actual surgery. The only way to become a good radiologic technologist is to learn how to administer actual X-rays and CT scans.

It’s a cost that tends to be hidden, especially from the public. It means finding clinics and hospitals willing to become training sites. It means investing time, energy and staff resources in supervising students and providing them with constant feedback. And although using trainees to deliver direct patient care might sound like a money-saving bargain, it often isn’t. Students typically are slower. They need to have their work double-checked. For organizations that agree to be training sites, it can come at the cost of lower productivity and lost revenue.

Rural facilities are especially at a disadvantage. Although rural training experiences are a valuable, and proven, way to recruit these health care professionals to rural practice, offering these opportunities can be a significant stretch for small clinics and hospitals where resources are already spread thin.

Policymakers have tried to offset the burden by allocating public money to help subsidize the expense of educating the state’s future health care professionals. In Minnesota, the Medical Education and Research Costs program, or MERC for short, has distributed more than $450 million over the last decade or so to hospitals, clinics and other sites that host clinical training. In recent years, though, the size of the fund has diminished. Once the bulk of the money is distributed to the state’s main teaching hospitals in the Twin Cities and Rochester, there’s little left over. In fact, 75 percent of the MERC funds in 2009 went to the 20 largest sites, while the majority of small community sites received less than $20,000. Many received nothing.

It should be noted that eligibility for MERC grants also is limited to certain types of training programs, primarily those that prepare students in medicine, dentistry, advanced-practice nursing, pharmacy, chiropractic and physician assistants.

An obvious solution to the rising cost of training health care professionals is to shift the financial burden onto students by charging higher tuition. To some extent this has already happened. At a certain point, though, it can become unsustainable. Probably the best example is medical school: The average student now graduates from medical school with $156,456 in educational debt, according to the American Medical Association. The main reason? Rising tuition costs. Not only is it burdensome for students but there’s also some evidence that their loan obligations are influencing many students’ career choices when they complete their training, driving them toward higher-paying specialties at the expense of primary care. The daunting costs also can discourage bright young people from even considering a career in health care.

It’s not clear what the solution should be. What’s obvious, though, is that many clinics and hospitals are continuing to offer training opportunities and hands-on experiences for students in the health professions. They do it because they’re committed to helping develop a health care workforce that’s skilled and competent and can carry their communities forward into the future. They’re certainly not doing it for the money.

Photo: A University of Minnesota dentistry student gains skills in cleaning teeth and working with children while participating in a rural training rotation at the Rice Regional Dental Clinic in Willmar. West Central Tribune file photo.

A new paradigm for pre-meds?

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To be admitted to medical school, it has always taken good grades and a strong background in the sciences. Most pre-med students load up on college courses in biology, chemistry, physics and math. Twentieth-century American history or the poetry of Yeats? Not so much.

There’s traditionally been a strong belief that college students pursuing their premedical studies should concentrate on the sciences rather than the humanities, and that this preparation will make them more successful in medical school and ultimately help them become better physicians.

A new study, published in the August edition of the Academic Medicine journal, has come along to punch a few holes into this belief. The title more or less sums it up: “Challenging Traditional Premedical Requirements as Predictors of Success in Medical Schools: The Mount Sinai School of Medicine Humanities and Medicine Program.”

The study involved about 700 medical students at the Mount Sinai School of Medicine in New York. Eighty-five of these students were enrolled in the school’s Humanities and Medicine Program; the rest took traditional coursework. After analyzing and comparing data on academic outcomes for the graduating classes of 2004 through 2009, the authors concluded, “Students without the traditional premedical preparation performed at a level equivalent to their premedical classmates.”

In the interests of full disclosure, I graduated from a liberal arts college where most of my coursework was in the humanities. I’ve been increasingly disturbed at how the sciences are pushed on young people as the ticket to a “good” (read: lucrative) career, the implication being that the humanities don’t hold the same value. So reading about this study in Academic Medicine made my nerdy little English major’s heart skip a few beats.

Among the findings: Students enrolled in Mount Sinai’s Humanities and Medicine Program were just as likely as their peers to graduate from medical school with honors or distinction. Interestingly, they also were more likely to choose residencies in primary care and psychiatry, and less likely to gravitate toward anesthesiology and surgical subspecialties. They did not perform as well on the U.S. Medical Licensing Examination Step 1, which may have been a reflection of their nonscience background or perhaps how the test itself is structured. The study’s authors noted, however, that even with slightly lower test scores, this “seems unlikely to affect their clinical skills or to keep them from securing high-quality residency training positions.”

The Humanities and Medicine Program is intriguing in and of itself. Qualified college sophomores and juniors majoring in the humanities or social sciences who sign up for the program are guaranteed admission to the Mount Sinai School of Medicine. (Lest anyone think it’s easy to get in, it’s not: The selection criteria include high school and college grades, SAT scores, two personal essays, three letters of recommendation and two interviews at Mount Sinai.) Once accepted into the program, HuMed students don’t have to take organic chemistry, physics or calculus, nor do they have to take the MCAT exam. They do have to maintain at least a 3.5 grade point average, however, and they also must earn a B or better in biology and chemistry.

There’s no program like it at any other medical school in the U.S., so it’s hard to know whether the findings from this study can be replicated elsewhere. Nor did the study look at how Mount Sinai’s HuMed graduates fared in clinical practice.

It all raises some interesting questions, though, about how we prepare future physicians here in the United States. Do pre-med students really need to sweat their way through organic chemistry in order to meet the admission criteria for medical school? Do medical schools needlessly skew the application process? Have they tilted too far toward the sciences and away from the humanities, and is this in some way detrimental to producing physicians who are well-rounded human beings?

It’s a somewhat controversial question in academic circles. There’s been little movement, though, to address it more fully, the journal article acknowledges:

Despite general agreement that many premed requirements are of limited educational value for the practicing physician or active scientist and that a broad liberal arts education provides direct benefits to practitioners and their patients, little progress has been made toward a fundamental reappraisal. In 2009, over 80% of matriculating applicants entered medical school with majors other than the humanities or social sciences. The belief that the premed science background (including one year each of organic chemistry, physics, and calculus) is the best form of student preparation for medical school persists, and admissions committees’ reliance on exceptional MCAT scores prevails.

This emphasis on the sciences percolates all the way down to high school and even junior high. Career counselors urge students interested in medicine to start beefing up their science background as soon as possible. It’s thought by many observers that if students wait until their junior or senior year in high school, it’s too late. You can’t help wondering about the long-term impact of this do-or-die channeling of young people’s interests and the academic choices it often forces them to make.

To be a good clinician, unquestionably it takes a strong background in the sciences. Majoring in the sciences does not necessarily turn someone into a soulless robot, just as an emphasis on the humanities doesn’t necessarily guarantee someone will be perceptive and empathetic. It’s worth asking, however, whether a more balanced premedical education would ultimately be better both for doctors and for their patients. This study offers at least some preliminary evidence that it’s possible for medical students to hold their own even when they haven’t spent all their college years in the science lab.

Update, Aug. 11: Here’s a personal perspective on this issue from Dr. Bob Wachter, who majored in political science.

Photo: Wikimedia Commons